This is a continuation of a long topic, addressed by post number rather than by page. Start at post 1.
The four-week step is a trial convention, not a pharmacological constant. It is roughly four half-lives for a week-long half-life, which is the interval at which you are assessing a stable concentration rather than a rising one.
Stating my assumptions rather than smuggling them in.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
The right answer here may simply be that it has not been measured.
Post #30 is the version of this I will quote in future. One addition.
Splitting a weekly dose in two: the pharmacokinetic argument against is that you want the benefit of long half-life, which gives a slowly changing plasma level from a weekly dosing schedule. Splitting it flattens the curve further but loses the convenience of once-weekly dosing. The trade-off is convenience versus a slightly flatter concentration curve.
This is the first time the answer has come with its own limits attached. Appreciated.
A missed dose in a weekly schedule is not a trough to chase. With a week-long half-life you are perturbing a slowly moving average, and the labelling for licensed products in this class says take it if the next dose is far enough away and skip it otherwise.
Take it as a starting point and not as a specification.
Where I part company with post #37, and it is a narrow parting.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Narrowing post #38, because the general version has more than one answer.
Writing down the date, the dose and the site each week takes fifteen seconds and is the single most useful record anyone here keeps. Memory reconstructs a titration history that never happened.
Everything in post #37 holds. The case it does not cover is the one I have.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Going back down a step is not a failure and the trials allowed it. Several protocols permitted a return to the previous dose for tolerability and then a second attempt at the step.
Two people can read the same figure differently here and both be reasonable.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
One of those cases where knowing the mechanism does not help the decision.
Doubling after a miss adds a peak for no gain and is not what any labelling in this class recommends. That is a description of the labelling rather than advice about anyone's situation.
I would treat that as a working assumption and revisit it.
Post #41 answers the question as asked. The question underneath it is different.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Split dosing within a week is sometimes proposed to smooth tolerability. With a week-long half-life the concentration is already smooth, so what it would change is the timing of the peak rather than its existence.
I have written this out at length because the short version keeps being misread.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Written quickly, so the reasoning may be tighter than the wording.
Stepping down deliberately: the withdrawal trials show that stopping is followed by regain. The step-down literature is thinner. The conservative assumption is that stepping down is followed by some regain, with the magnitude unknown.
Noting that the question and the thing people usually mean by it are different.
Titrating on symptoms rather than on the calendar is what most people here actually do. It is defensible, it is not what was studied, and describing it as the protocol would be wrong.
Going back down a step is not a failure and the trials allowed it. Several protocols permitted a return to the previous dose for tolerability and then a second attempt at the step.
A single observation, in a thread that deserves better than single observations.
Post #52 is right about the mechanism and I think understates the practical bit.
Reaching a dose and staying there for a year: the question of whether a stable dose remains effective over years is mostly answered by the withdrawal trials and by real-world reports. The dose does not seem to stop working, but the longest trials are not indefinitely long.
Worth separating two things that post #54 runs together.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.
Post #56 answers the question as asked. The question underneath it is different.
Writing down the date, the dose and the site each week takes fifteen seconds and is the single most useful record anyone here keeps. Memory reconstructs a titration history that never happened.
A titration plan written down in advance is easier to stick to and easier to abandon deliberately. An improvised one becomes a series of decisions made on the worst day of each week.
Adding it because I spent an afternoon working it out and nobody should have to twice.
Useful. I had the fact and not the reason, which turns out to be the important half.
Concentration and dose get conflated constantly in this subcategory. Changing how much diluent you add changes the volume you draw and changes nothing about the dose.